61-65 BOSTON ST - BPA-10-891 PROCTOR CROSSING ,. The Commonwealth of Massachusetts
Department of Public Safety
\la.,.ich LINO t.State Building Code(780 C SIR)Seventh Edition
City of Salem
Building Permit Application for any Building other th a 1- or 24 4milyDwellinjt
(\� (this Section For Official Use Onlv)
Building Permit Number: Date Applied: Building I . T
1 SECTION l: LOCATION (Please indicate Block N and Lot 0 for locations for wh' et address is not available)
(o(-&,Zi ST, G /rub
No. and Street Citv /Town Zip Ctkle Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Sr I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No OV
Is an Independent Structural Engineering Peer rw re uired. � Yr- A` No W
Brief Description of Proposed Work: �r4 b'a � �` 7 /Zi`i�_fi //` (=�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ -
Existing UseGroup(s): FPioposed UseGroup(s): P
Existing Hazard Index 780 CMR 34: _ Proposed Hazard Index 780 CMR 34:
-'SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicii le)
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ - A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 O
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as Applicable)
IA ❑ 180 IIA ❑ 11813 IIIA ❑ II18 ❑ IV ❑ 1 VA VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Sup : Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
:\ trench will not be Licensed Di.pu..tl Site❑
Public Check it outside Flo..d Zone❑ Indicate municipal♦� required ❑or trench or.
Prirate❑ or mdentifr Zone: or on one,%,tem ❑ 1 I.uty:
permit i.enclosed ❑ _
Railroad right-of-wary Hazards to Air.Vavig,ition: \1.\ I list.•rn ( ,,nuns wn R...uo.. Pn ....:
\nl : pplicable�G 1.�trurturo",1
.nhm.urport.tpF+ru,trh area.' h lhao rrric•w completed'
ur 1 ,gt.cnl In Rudd cndowd ❑ 1 vN❑ nr No Yes❑ \0 51"
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
L.iiu.m „I C„de: L.e Cn ntplNe itpeol Con,truchtm: Occupant Load per 11,,
It„c.the buil.iutt;anumn.ut Sprinkler S%,tem.': Special SupulauonN:
t�•c- �7 C -
tN
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ad iress of Properiv Owner L.�
F L L�C aD3 wf6I1W{`c)q 5, aS 1 tol9 >b
Name(Print) - No.and Street Cii Town Zip
Pr nerXontact Information:
Title Telephone No. (business) Telephone No. (cell) a-mad address
If placable, the property owWr herobv Wth razes n,t,
n��� Lei y,A04c�i t S boa Q a QIJ t O-V¢S2 Mh- o 1R ( S
Name Street Add Citv/Town State Zip
to act on the +ru perty,m ner's behalf, in all matters relative to work authorized by this buildin • permit a p pbcation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,tx1U cu.It.of enclosed s ace and/ar nut tinder Construction Control then check here O and skip Suction 10.1)
10.1 Registered Professional Responsible for Construction Control
- r
Name(R�istrant) Telephone Nu. M t Ul_ e-mailaddress ( Registration Number
I ll�odt oz S I— fzlv�y f b_n(
Street Address City/Town— State Zip Discipline Expiration Dale
10.2 General Contractor
�v\v�� T LN�y
Company Namr: Q p,
>n k s �A vy �2� CS (z 1 l(ncZ�
Name of Person Res )nsible for Const cacti n License No. and Type if Applicable
/Atka—i DOA-- r-?t 0% i C
Street Address `S City/Towd State Zip
15-910 000--7 ——
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(Q)
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) - Total Construction Cost(from Item 6) _$ �� OCJO
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=S (contact municipality)
5. Mechanical (Other)- $ - Enclose check payable to aas. vv�
6.Total Cast S (contact municipality)and write check number hereq.S
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herobv attest tinder the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and Understanding.
U Q7�'.SrtU . Cfrb7 S tSr 10
Please p m + d a);n name Title Telephone.No. Dale
C
titrect :1.41re(S 0 / / CitTP Stat Lip
o(�[ ll
.Municipal Inspector to fill out this section upon application approval: Z 't 0
- Narnei D.ue